Heart attacks, as already noted, are the result of a clot in an artery to the heart.
However, while they seem to occur suddenly and often without warning, the process
underlying the event has been going on for many years. Underlying the clot is a disease of
the artery wall called arteriosclerosis. When arteriosclerosis occurs in one or more of
the vessels to the heart, it is termed "Coronary
Artery Disease". HeartPoint has a substantial section devoted to this topic.

Cholesterol deposition in the artery wall leaves less room for the blood to flow
through the channel in the middle. Furthermore, it leads to inflammation which may eat
away at the cells lining the artery. Thus, the contents of the plaque may be exposed to
the bloodstream. When a substance other than what is supposed to is sensed within the
bloodstream, the bodys natural reaction is to build a clot around it to keep it from
doing damage. If the clot grows too large, the artery is occluded and a heart attack
results.

Factors other than cholesterol are important in the development of Coronary Artery
Disease. Risk factors include smoking which

Damages the lining to the arteries

Promote the clotting of blood

Lowers the level of "good" cholesterol in the blood, and

Promotes spasm of the vessels, tending to keep it closed.

Other factors which promote coronary artery disease are high blood pressure, diabetes,
male sex, sedentary lifestyle, overweight, and family history of the problem. Again, you
might check the link above to learn more about these

Are there any other causes of heart
attacks?

An occasional heart attack is caused as the result of an "embolus". This is a
blood clot which is formed elsewhere and then travels to the coronary artery. In the case
of heart attacks, the clot is generally formed in the left atrium or left ventricle and
then migrate to a coronary artery. This is quite uncommon. Blood thinners are often
prescribed to patients who have had such an event to prevent more from occurring.

"Spasm" of the muscle which surrounds the artery can occur. This shrinks the
size of the passageway for blood too, and may be associated with an increased tendency of
the blood to clot. This is often associated with atherosclerotic disease as well, although
it is usually mild. It can be particularly severe with smokers, or those who abuse cocaine
or similar drugs. It is important in these cases that the proper medicines are prescribed
and taken to minimize the risks of further arterial spasms.

What are the symptoms of a heart attack?

The classic symptoms of a heart attack are pain in the chest, neck, jaws, back,
shoulders, or arms. The pain may be severe, but is most often moderate in intensity. The
pain may be described as "crushing", "heavy" or
"pressure-like". These same sensations can occur in the other locations we just
mentioned. People often say "it's like an elephant on my chest".

The event is often associated with a distinct sense that something is really wrong.
This pain can be associated with intense sweating, and this is a key sign that a heart
attack is occurring. Shortness of breath, nausea, or vomiting also commonly occur.

The seemingly commonplace assumption that the pain must involve the left arm is
completely false, and has caused a great deal of confusion by the lay public. The right
arm is very frequently involved instead of, or along with, the left arm. There may be no
pain in the arms at all.

Symptoms of a heart attack should prompt one to inform other people in the area that
such symptoms are occurring. You should not attempt to drive, or even have someone else
drive you to the hospital, but simply call 9-1-1 or the emergency services in your
location immediately.

What about those "clot busting"
drugs?

"Clot Busters" have been proven to be effective in lowering mortality from
heart attacks. The key here is how soon they are given. They are generally very effective
in the first 2-4 hours, still pretty good if given within 6 hours of the onset of
symptoms, and can show a measurable effect in large studies if given within the first 24
hours. After this period of time, they just do not offer any advantage.

The reason for this time-dependence is simple. The longer the artery has been closed,
the more likely it is that the muscle in its distribution will die. If given early, there
may be substantial, and sometimes complete, reversal. If given later, all of the muscle
may already be dead, and in that case, it will not require further blood flow.

There are significant risks to these potent clot busting medications (we're not talking
here about simple blood thinners). Serious bleeding may occur which may require surgery or
transfusions to correct. There is also a chance of bleeding in and around the brain, which
may cause very serious strokes and death. Other bleeding complications, and occasional
allergic reactions, may also occur. On balance however, in many cases the overall risk of
a bad outcome is reduced by these "miracle" drugs. Patients who present early in
the course of their heart attack and have an opportunity to receive them can experience a
marked decrease in mortality.

What is sudden cardiac death?

Death which occurs suddenly after the onset of a heart attack is most often due to
unstable electrical rhythms, specifically ventricular tachycardia and ventricular
fibrillation, which do not allow the pumping chamber of the heart to pump efficiently and
use up its supply of oxygen. This event can be rapidly reversed with the use of
medications or shocks from a defibrillator. Since even this potentially catastrophic event
can be reversed, it is imperative that emergency personnel be summoned at once if you
think you are having a heart attack.

My doctor said I had a "silent heart
attack". How is that possible?

Although the general perception of a heart attack seems to be that it is an incredibly
painful process, often it causes only relatively mild pain. It may be misinterpreted by
the person experiencing it as "indigestion" or "heartburn" or ascribed
to other entities such as a sore shoulder or arm. Since most heart attacks aren't fatal,
the person may just go about their business wondering why they were a bit more tired than
usual. Later on, a study such as an electrocardiogram is done which suggests that damage
has occured, and the patient may or may not remember the incident.

Furthermore, some patients have a "defective warning system" -- they simply
do not have the perception of the pain. This can occur in anyone, but is more common in
diabetics who may have some nerve fiber damage as a result of the high sugars. Older
patients also tend to have silent heart attacks, or at least heart attacks that are
associated with unusual symptoms.

It is also worth noting that this term of a "silent heart attack" can be used
pretty loosely by people, even medical professionals. There are some patterns on the
electrocardiogram which can be misleading, and it is often necessary to obtain more
sophisticated and precise tests to be sure that indeed some damage has occurred.

Whats a "coronary"?

Its really just another term for a heart attack or MI.

What's the difference between
"angina" and a heart attack?

"Angina" is the pain that may be felt when there is a temporary imbalance
between the heart muscle's demand for blood and the ability to deliver enough blood
through the arteries. The pain may be very similar to that of a heart attack, but is often
more severe and almost always lasts for a shorter period of time (usually 3-30 minutes).
It is also similar to a heart attack in that there is inadequate flow of blood to the
heart muscle, but in the case of angina the lack is temporary and the heart muscle does
not die and later scar as it does in the case of a heart attack.

What's the difference between a stroke and
a heart attack?

A stroke is a lack of blood to the brain. A heart attack is a lack of blood supply to
the heart. Both usually involve clogged arteries and blood clots.

How big was my heart attack?

The family and patient generally want to know right away and very precisely the amount
of damage. Generally, it takes several days to get the best picture of the size of the
heart attack.

Even then, it is difficult to measure the size of a heart attack with precision.
Certain findings on the electrocardiogram can give an idea of the size of the area
damaged. There are other ways to change as well. When heart muscle cells die, they release
their contents into the blood. Some of these materials are substances called enzymes, such
as "CPK" (creatinine phosphokinase) which can be measured in the blood. If very
frequent blood tests are done measuring the release of these enzymes, a pretty fair
estimate can be given.

Other ways to tell the size include visualizing the muscle and its movement using
studies such as echocardiograms or nuclear medicine studies such as RVG's (radionuclide
ventriculograms) which are also known as MUGA's (multiple gated acquisition). Other
nuclear studies, such as "thallium scans" can estimate the size of the scar in a
somewhat different manner. Wall motion is also usually assessed when and if a heart
catheterization is done. New developments, such as "PET scans" (Positron
Emission Tomography") are more precise. The devices are very expensive and not
generally available.

The point of all of this however is not that all or any of these sophisticated and
costly studies must be done. Doctors generally can usually make a pretty good estimate
from the electrocardiogram and blood tests, and use one or two of the other tests to help
confirm their impression.

What happens after a heart attack? How
long do I stay in the hospital? What will I do while Im there?

The type and duration of treatment has changed over the years. Twenty years ago,
patients were still put at bedrest, sometimes absolute bedrest, for two weeks or longer.
Nowadays, that is abbreviated to one or less days. The hospital stay and type of
evaluation depends on several factors, with most people now staying 3-5 days after a heart
attack unless other procedures are necessary.

During this time, they will gradually increase their activities to the point where they
are doing all of their own self-care such as bathing and eating, as well as beginning a
walking program as part of their rehabilitation program. Many hospitals offer a
"Cardiac Rehab" service consisting of personal and video education, instructions
in diet and exercise and stress reduction, and explanations on the nature of the disease
process. Medications can be administered, and their doses adjusted.

Certain tests may be done in the hospital. The patient's heart rhythm is often
continuously monitored throughout the time they are in the hospital to assess for any
abnormal heart rhythms which may occur. Other tests may be done, including
echocardiograms, nuclear medicine studies, and cardiac catheterizations. In some cases,
therapeutic procedures such as angioplasty or bypass surgery are done before the patient
is sent home (see below).

When can I go back to work? Are there any
limitations?

Hopefully, your eagerness to get back to work does not indicate a "Type A"
personality  one that thrives on high pressure situations constantly. This could be
one of the reasons you had a heart attack in the first place.

Otherwise, it is of course a reasonable question. Work is generally a positive force in
our lives (particularly our financial lives), and needs to be tended to. Patients are
generally allowed to return to work in 3-6 weeks, although most will be limited to
carrying no more than 40 pounds for the first 3-6 months. It is often recommended that the
person go back for half-days if possible for the first week. Long hours should be avoided.

Specific recommendations depend on many specifics of your situation, and are
individualized by your physician.

What about sex after a heart attack?

Like the other areas of life we've spoken about, the goal is to return to the level of
activity before the heart attack, if not actually improve it. Sexual intercourse does
require energy, and causes the heart rate and blood pressure to increase. The degree to
which the heart is stressed is not appropriate soon after a heart attack. As physical
activities resume and gradually are increased, the body and the heart will be more able to
withstand this moderate stress without causing problems. The physical demands are similar
to walking up a couple of flights of stairs at a brisk pace.

Resuming sexual relations after a heart attack often involves more than the physical
aspects of the stress on the heart. It is not unusual for the patient or their partner to
be at least somewhat fearful. Some degree of depression is also often present after an MI,
and new stresses are introduced into the relationship as a result of new roles, financial
pressures, and the like. Medications may affect sexual performance in some cases.

Most people who have had heart attacks are generally able to resume sexual relations in
about four weeks. This needs to be individualized however, and you should ask your
physician for specific recommendations about the timing. The position of the patient (on
the top or on the bottom) does not make a great deal of difference in the amount of demand
on the heart. The risk of sudden death during intercourse is very low, but is somewhat
higher in the situation of an extramarital affair. If one experiences angina during
intercourse, nitroglycerine may certainly be used. Discussion with your physician can lead
to strategies to prevent angina, such as taking a nitroglycerin 5-15 minutes before
beginning.

Thus, sex may not be the same at first. Recognition of these factors, and reasonable
expectations will help the relationship grow once again, however. You should really seek
the advice and counsel of your physician if you are experiencing problems or have any
questions. It really can help.

I don't feel the same since my heart
attack. Why?

It is not unusual to be fearful, resentful, depressed or angry after a heart attack. It
is a tough pill to swallow sometimes, and does not appear to be fair. However it is
important, very important, to realize that these feelings are normal, and will just as
normally fade away as you understand and recover. If you are having problems, work to put
things in perspective and remember to give things some time. Family members can bear the
brunt of these emotions. They should be aware of the difficulties you may be experiencing
to minimize their pain, and maybe help you as well.

Above all, discuss this with a friend, clergy, or your physician if it continues or
becomes too painful. You can be helped, and will recover.

Should I join a Cardiac Rehab program?

Many people benefit from inpatient and outpatient Cardiac Rehab. This generally
includes:

These programs are not always covered under some insurance plans. Check with your
company. If its not, see if the Rehab group can offer a discount so you can afford
it.

Will I need to take medications?

Almost certainly. Aspirin has been shown to reduce the risk of second heart attacks,
and either it or another blood thinner is almost always prescribed.

Several other agents have been shown clearly to reduce mortality in most patients after
a heart attack, including:

"Beta Blockers"

"ACE inhibitors"

Some cholesterol lowering agents

Some or all of these may be prescribed, and will be advantageous to take.

Does cholesterol have anything to do with
this?

You bet it does. There is a strong link between the level of cholesterol in the blood
and the buildup of cholesterol in plaques in the arteries. Not only is the level of
cholesterol important, but the type ("good" or "bad") has a lot to do
with it. For more about Cholesterol, check it out
elsewhere on HeartPoint.

Bur, my doctor says my cholesterol reading
is inaccurate right after a heart attack. Why is it so?

The heart metabolizes fat and cholesterol, particularly when it is stressed. It has
been shown that the cholesterol levels are not accurate for several months after a heart
attack. Further testing is often put off until then.

Can I still smoke?

Absolutely not!

Am I going to need to have bypass surgery
or a balloon procedure?

Some people do, others dont. The fact that someone has had a heart attack
is no absolute indication that they require one of these invasive therapies (called
"revascularization procedures").

Some factors that favor the need and benefit of a revascularization procedure include:

The continued recurrance of chest pain after the heart attack has initially
"completed".

Evidence that there is still muscle in the distribution of the diseased artery which is
at risk of dying if the vessel should totally occlude again. That is, it is suspected that
although the artery did close at the time of the heart attack, it reopened enough to let
some blood through and "salvage" some of the muscle in its distribution.

Moderate, but not minimal nor huge amounts of muscle damage.

The vessel causing the heart attack being large with more than minor but less than total
blockage.

Some factors which would tend to favor a "less aggressive" approach (that is,
treat with medicine alone) include:

A totally blocked vessel. Quite simply, this vessel cannot get any worse. A 100%
blockage is less of a threat in most cases than those that are blocked from 90-99% which
have a high incidence of repeat closure and another heart attack.

A blockage of less than 50-70%.

Vessels where there is a lot of blockage, but where it appears that all of the damage
has already been done. For example, if all of the muscle in the distribution of an
artery has died, there is no need to bypass that vessel, since it will only supply a scar.
Remember, it is the muscle that's important -- the only point of an artery is as a conduit
to that muscle.

It is also not unusual to find out that other heart arteries have blockage, and this
will also influence whether bypass or balloon procedures are required.

My doctor said I only had a small heart
attack, but that Im still at high risk. How can that be?

He is probably referring to a "Sub-Endocardial MI" (aka "non-Q
MI"). A small MI, as judged from the amount of enzyme released, may occur from one of
two situations:

A large artery closed long enough to cause some damage, but later re-opened enough to
prevent all of the muscle in its territory from dying, or

A small artery closed completely, with essentially all of the muscle in its territory
dying.

The amount of enzyme released in each case will be similar. However, in the first case,
a significant blockage may still be present, and more damage is still possible if it
closes again -- this is the high risk situation that is being referred to. In the second
case, all the damage has already been done, and the chances of a bad outcome are less.

My doctor says Im having a lot of
irregular rhythms after my heart attack. What does that mean?

There are many different types of arrhythmias (see the sections on Arrhythmias
elsewhere in HeartPoint). Usually, the most concerning types after a heart attack are
ventricular arrhythmias, which may be associated with an increased incidence of death. The
proper evaluation and treatment of ventricular arrhythmias following a heart attack is
quite important, but may require longer hospitalizations and more testing.

My brother (or mother or father or sister,
etc.) had a heart attack. Does that mean Im going to have one too?

Atherosclerosis and coronary artery disease do have a strong genetic component. Having
a first-degree family member (parent or sibling) with the disease increases your risk . .
. but its not a death sentence! Talk to your physician, undergo screening tests if
necessary, and follow the 10 Step Program below.

Ive known many patients with a strong family history who lived long and healthy
lives without the slightest trouble from their heart. Dont give up because of
something like a family history . . . do all of those many things which can be done to
prevent it.

What can be done to prevent another one?

Heres a pretty simple 10-Point Plan:

Dont smoke

Take an aspirin a day (as long as you have not been told not to).

Control your blood pressure, with medications if prescribed.

Keep diabetes under control if it is present.

Follow your prescribed low-fat diet.

Have your cholesterol checked. Take medications if prescribed.

Pursue at least a modest and regular exercise program.

Strive to attain ideal body weight with a prudent diet and exercise program.

Follow-up regularly with your doctor and follow the instructions you receive.